Does the Belgian diabetes type 2 care trajectory improve quality of care for diabetes patients?

Abstract

BackgroundThe Belgian care trajectory (CT) for diabetes mellitus type 2 (T2DM), implemented in September 2009, aims at providing integrated, evidence-based, multidisciplinary patient- centred care, based on the chronic care model.The research project ACHIL (Ambulatory Care Health Information Laboratory) studied the adherence of CT patients, in the early phases of CT programme implementation, with CT obligations, their uptake of incentives for self-management, whether the CT programme was targeting the appropriate group of patients, how care processes for these patients evolved over time and whether CT start led to better quality in the processes and outcomes of care.MethodsThis observational study took place in the period 2006–2011 and covered T2DM patients who started a CT between 01/09/2009 and 31/12/2011.Four data sources were used: outcome data, from electronic patient records (EPRs) on all CT patients, provided by general practitioners (GPs); reimbursement process data on all CT patients and clinically comparable patients; and data from a sample of CT patients and clinically comparable patients from an EPR-based regional GP network and a paper-based national GP network, respectively.Through multilevel analysis of cross-sectional and longitudinal data, the effect of CT inclusion on processes and outcome was estimated, controlling for potential confounders.ResultsBy the end of 2011, data on 18,250 CT patients had been collected. Approximately 50 % of these CT patients had received reimbursement for a glucometer and nearly 60 % had had at least one encounter with a diabetes educator. The CT programme recruited T2DM patients who had been difficult to control in the past. In the years prior to CT start, there had been a gradual improvement in the follow up of these patients. Moreover, compared to non-CT patients, the proportion of CT patients adhering to the recommended frequency for monitoring of parameters, such as HbA1c, increased significantly around CT start. Some data sources, albeit not all, suggested there had been an improvement in certain outcomes, such as HbA1c, after CT inclusion.ConclusionsAccording to this study, CT enrolment is associated with better quality of care processes compared to non-CT patients. This improvement was found in several of the data sources used in this study. However, results on outcome parameters remain inconclusive.

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“…It was based on the Chronic Care Model [24] but was disease-specific and only included a limited subset of patients in the advanced stage of each disease. As part of this policy, a contract between patient, GP and specialist is used to support interaction between these three actors [25]. Financial incentives are provided for the physicians and better access to self-monitoring material and education is granted to the patient.…”

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“…A GP-practice is considered as multidisciplinary, when it consists of one or more GPs and at least one nurse and/or dietician. We opted for these two disciplines in addition to the GP, as these play a prominent role in T2D management [40]. Based on these dimensions, four types of GP-practices can be distinguished in theory, but in practice, only three types actually exist in Belgium (Flanders) [41]: (a) monodisciplinary and FFS, (b) multidisciplinary and FFS, and (c) multidisciplinary and a capitation payment system in which patients subscribe for an annual xed fee.…”

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“…These educators, i.e. general practice nurses with a special training in diabetes care, instruct patients included in a care trajectory and have improved quality of care processes [ 41 ].…”